Can a New Cognitive Therapy Approach Help People with OCD?

What you need to know

• A new cognitive therapy approach called trial-based cognitive therapy (TBCT) was compared to standard exposure and response prevention (ERP) therapy for treating obsessive-compulsive disorder (OCD)
• Both TBCT and ERP significantly reduced OCD symptoms after 12 weeks of treatment
• The benefits of both treatments were maintained 12 months after treatment ended
• TBCT may be a promising alternative treatment option for OCD, especially for patients who have difficulty with exposure therapy

Understanding OCD and Its Treatment

Obsessive-compulsive disorder (OCD) is a common mental health condition that affects 1-3% of people worldwide. People with OCD experience intrusive, unwanted thoughts (obsessions) that cause anxiety, and feel compelled to perform repetitive behaviors or mental acts (compulsions) to reduce this anxiety.

For example, someone may have obsessive thoughts about contamination and germs, leading them to compulsively wash their hands dozens of times per day. Or they may have intrusive thoughts about harm coming to loved ones, compelling them to repeatedly check that doors are locked.

OCD can significantly impact a person’s daily functioning and quality of life. The two main treatment approaches for OCD are:

1. Medication - Usually selective serotonin reuptake inhibitors (SSRIs)
2. Psychotherapy - Typically cognitive-behavioral therapy (CBT) or exposure and response prevention (ERP) therapy

ERP is considered the gold standard psychological treatment for OCD. It involves gradually exposing the person to situations that trigger their obsessions while preventing them from performing compulsions. Over time, this helps reduce anxiety without relying on compulsive behaviors.

However, ERP can be very challenging for patients, as facing feared situations without being able to do compulsions often causes intense anxiety initially. This leads some patients to drop out of treatment. Additionally, ERP may not fully address the underlying beliefs and thought patterns that drive OCD symptoms.

A New Cognitive Therapy Approach

Researchers have been exploring whether cognitive therapy approaches that focus more directly on modifying thoughts and beliefs related to OCD could be effective alternatives or additions to ERP.

This study examined a newer form of cognitive therapy called trial-based cognitive therapy (TBCT). TBCT uses techniques that are analogous to a legal trial, with the patient playing different roles like defendant, prosecutor, and judge. The goal is to help patients examine and modify core beliefs that may be contributing to their OCD.

Some key features of TBCT include:

• Using a step-by-step approach that integrates cognitive and behavioral techniques
• Focusing on changing underlying core beliefs, not just surface-level thoughts
• Using an easy-to-understand case formulation model
• Incorporating experiential techniques like role-playing

Previous research has found TBCT to be effective for conditions like social anxiety disorder, post-traumatic stress disorder, and depression. This study aimed to see if it could also be beneficial for OCD.

Comparing TBCT to Standard ERP Treatment

The researchers conducted a randomized controlled trial to compare TBCT to ERP for treating OCD. Here’s an overview of how the study was conducted:

• 26 adults with OCD were randomly assigned to receive either 12 weeks of TBCT or 12 weeks of ERP
• Treatments were delivered in weekly 1-hour individual sessions
• OCD symptoms were measured before treatment, after treatment, and at 3, 6 and 12 month follow-ups
• Symptoms of depression and anxiety were also assessed

The main goal was to see if TBCT could reduce OCD symptoms as effectively as the gold-standard ERP treatment.

Key Findings

The results showed that both TBCT and ERP led to significant improvements in OCD symptoms:

• TBCT reduced OCD symptoms by 47% from pre-treatment to post-treatment
• ERP reduced OCD symptoms by 43% from pre-treatment to post-treatment

Importantly, these benefits were maintained 12 months after treatment ended:

• TBCT reduced symptoms by 53% from pre-treatment to 12-month follow-up
• ERP reduced symptoms by 44% from pre-treatment to 12-month follow-up

There was no statistically significant difference between the two treatments in terms of symptom reduction. In other words, TBCT appeared to be about as effective as ERP for treating OCD.

Both treatments also led to improvements in depression and anxiety symptoms. Again, there were no significant differences between TBCT and ERP on these measures.

Clinical Significance of the Results

In addition to looking at average symptom reduction, the researchers examined how many patients showed clinically meaningful improvement. They used standardized criteria to classify patients as “improved” or “recovered” based on their symptom scores.

At the 12-month follow-up:

• 67% of TBCT patients were classified as “improved” compared to 23% of ERP patients
• 56% of TBCT patients were classified as “recovered” compared to 8% of ERP patients

While the overall sample size was small, these results suggest TBCT may have led to more patients achieving substantial and lasting improvement compared to ERP. However, larger studies are needed to confirm this finding.

Implications and Future Directions

This preliminary study indicates that TBCT could be a promising alternative treatment option for OCD. Some potential advantages of TBCT include:

• It may be more acceptable to patients who have difficulty with the anxiety-provoking nature of ERP
• The focus on modifying core beliefs may lead to more complete or lasting change for some patients
• It could be especially helpful for OCD patients with comorbid conditions like depression

However, it’s important to note that this was a small pilot study. The researchers emphasize that larger clinical trials are needed to more definitively compare the effectiveness of TBCT and ERP for OCD.

Some limitations of the current study include:

• Small sample size of only 26 patients total
• Lack of a control group that received no treatment
• Patients and therapists were not blinded to which treatment they received

Future research should address these limitations with larger, more rigorous trials. Studies could also examine whether combining elements of TBCT and ERP leads to better outcomes than either approach alone.

It would also be valuable to identify if certain types of patients or OCD symptoms respond better to TBCT vs ERP. This could help clinicians make more personalized treatment recommendations.

Conclusions

• Both trial-based cognitive therapy (TBCT) and exposure and response prevention (ERP) led to significant, lasting reductions in OCD symptoms
• TBCT appears to be a viable alternative to ERP for treating OCD, though more research is needed
• TBCT may be especially beneficial for patients who have difficulty tolerating exposure-based treatments
• Larger clinical trials should further investigate the effectiveness of TBCT compared to other OCD treatments